Provider Demographics
NPI:1689694523
Name:RICHARD G JOHNSON MD INC
Entity Type:Organization
Organization Name:RICHARD G JOHNSON MD INC
Other - Org Name:RICHARD G JOHNSON MD INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:GREENE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-914-5219
Mailing Address - Street 1:415 W CARROLL AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4208
Mailing Address - Country:US
Mailing Address - Phone:626-914-5219
Mailing Address - Fax:626-914-7846
Practice Address - Street 1:415 W CARROLL AVE
Practice Address - Street 2:STE 100
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4208
Practice Address - Country:US
Practice Address - Phone:626-914-5219
Practice Address - Fax:626-914-7846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45973174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA46488FOtherINDIVIDUAL MEDICARE ID
CA00A616960Medicaid
CA110086507OtherRAILROAD MEDICARE
CA00G459730Medicaid
CAWA61696AOtherINDIVIDUAL MEDICARE ID
CAWA46604AOtherINDIVIDUAL MEDICARE ID
CAWG45973EOtherINDIVIDUAL MEDICARE ID
CA00A464880Medicaid
CA00A466040Medicaid
CA00A466040Medicaid
CA00A464880Medicaid
CA110086507OtherRAILROAD MEDICARE
CAWA46488FOtherINDIVIDUAL MEDICARE ID
CA00G459730Medicaid
CA00A616960Medicaid